Direct Pay Form

  Authorization Agreement for Direct Payments (ACH Debits)

Please print out the form below, fill it in and mail to:
Pennichuck Water
 25 Manchester Street
 P.O. Box 1947
Merrimack, NH 03054-1947

Please call Customer Service with any questions:  603-882-5191

Company Name  (Pennichuck Water)____________________________________
Your Pennichuck Water Account #______________________________________
I (we) hereby authorize Pennichuck Water, hereinafter called the Company, to initiate debt entries to my (our)  ___Checking/NOW Account   ___Savings Account indicated below and the financial institute named below, and to debit the same to such account.
Financial Institute Name: _____________________________________________
Branch: _____________________________________________
City: __________________________ State: ________
Zip: _____________________________________________
Routing # : _____________________________________________
Account #: _____________________________________________
This authorization is to remain in full force and effect until at such time I decide to discontinue this payment service and have notified the Company in such a manner as to afford the Company a reasonable opportunity to act on it.
Name(s): _____________________________________________
(Please Print)
Address: _____________________________________________
Daytime Phone #: _____________________________________________
Signature _____________________________________________
Date _____________________________________________